Epidemiological surveys of pathological gambling: Critique and suggestions for modification

Epidemiological studies of problem and pathological gambling were examined for their accuracy. Fundamental flaws and biases were found in these surveys. These include problems with survey instruments; nonresponses and refusal bias; the exclusion of institutionalized populations; exclusion of other groups; and failure to protect against denial on the part of the respondent when others are present near the telephone. Based on the issues discussed, one can reasonably be expected to assume that most epidemiological surveys seriously underestimate the extent of problem and pathological gambling. Alternative strategies for addressing these issues are discussed. These strategies include the use of field interviews, surveys of institutionalized populations, frequent player surveys and significant other surveys. The value and potential problems of these approaches are also discussed.This is a revision of a paper presented at the 9th International Conference on Risk and Gambling, Las Vegas, Nevada.The author would like to thank Rachel Volberg and Mark Dickerson as well as conference participants for their valuable suggestions on an earlier draft of this paper.     

The factorial structure of pathological gambling

Pathological gambling has been characterised by DSM-III-R and DSM-IV as a disorder of impulse control with a proportion of gamblers identified as meeting criteria for a co-morbid diagnosis of Antisocial Personality Disorder. To date, empirical evidence in support of the notion that pathological gamblers as a group manifest elevated traits of impulsivity remains equivocal. Principal components analysis was used to investigate relationships between the constructs of impulsivity, psychopathy, DSM-III-R criteria for Antisocial Personality Disorder, psychological distress, criminal offending behavior and a range of other common psychological measures employed with pathological gamblers. The sample comprised 115 pathological gamblers, 80 consecutive gamblers seeking treatment from a general hospital psychiatric inpatient behavior therapy unit, and 35 volunteer Gamblers Anonymous attenders. Four primary factors were determined: psychological distress, sensation seeking, crime and liveliness, and impulsive-antisocial. Results suggest that pathological gambling consists of a number of discrete and reproducible factorial structures. The impulsive antisocial factor was found to be associated with gambling behavior and indices of poor psychosocial functioning.     

The medical model of pathological gambling: Current shortcomings

Occasional, regular and pathological gambling are distributed in the population as a continuum. Failure to find categorical features of pathological gambling weakens the medical model for this condition, and the implications of this model concerning treatment, both in relation to the possibility of controlled gambling as an acceptable goal, and as to the effectiveness of social manipulations, such as restrictions of gambling outlets. Differences in gambling behavior patterns between pathological and nonpathological gamblers has not been consistently demonstrated and though some support exists for a relationship between addiction to gambling and alcohol, this could be accounted for by other factors than an addiction-prone personality. While findings support a relationship between personality variables and pathological gambling, the concept of a single personality type associated with the behavior seems unlikely. Nevertheless, evidence of physiological differences between pathological gamblers and controls has recently been reported and if established would provide strong support for a medical model, particularly one which allows for an interaction of physiological and sociological factors resulting in dimensional distribution of gambling behaviors.     

Genetics of pathological gambling

Pathological gambling (PG) is an impulse control disorder and a model behavioral addiction. Familial factors have been observed in clinical studies of pathological gamblers, and twin studies have demonstrated a genetic influence contributing to the development of PG. Serotonergic, noradrenergic, and dopaminergic dysfunction have been reported as biological factors contributing to the pathophysiology of PG. Molecular genetic techniques have been used to investigate the role of genetic factors in PG. Molecular genetic research has identified specific allele variants of candidate genes corresponding to these neurotransmitter systems to be associated with PG. Associations have been reported between pathological gamblers and allele variants of polymorphisms at dopamine receptor genes, the serotonin transporter gene, and the monoamine-oxidase A gene. Although preliminary data suggest that some of these differences are gender-specific, more research needs to be performed to substantiate gender-specific genetic contributions to the development of pathological gambling. The review of the current findings on genetics of PG suggests that liability to PG is in part mediated by genetic factors. Additional studies are needed to replicate and extend these findings, as well as to better understand the influence of specific allelic variants to differences in biological and behavioral functioning.     

The development of pathological gambling in Sweden

The development and the social, psychological and cultural conditions of pathological gambling reported by 42 interviewed pathological gamblers were compared with data from 63 pathological gamblers identified by case-finding. The two studies gave similar results. Gambling on horse races, roulette and bingo were the only types showing a progressive increase in involvement over time. When gambling heavily 40% of the pathological gamblers regularily experienced a state of altered consciousness. When abstaining from gambling withdrawal-like symptoms were experienced by a third. Fifty-two percent reported at least one family member often gambling. Pathological gambling appears to be a secret behaviour, although there are collective features in its development.     

The prevalence of pathological gambling in Canada

This paper critically reviews prevalence estimates of problem and pathological gambling in Canada. Populations studied are adults, adolescents and primary school children. The proportions of pathological gamblers found in Canadian studies (ranging from 1.2% to 1.9% for adults) are similar to prevalence rates reported in the United States. Given the apparent link between gambling availability and increases in the prevalence of problem and pathological gambling, it is hoped that provincial and federal authorities in Canada will make investments in research and treatment of pathological gambling in the future.The author wishes to thank Mark Freeston for his helpful comments. Portions of this paper were written while the author had grants from Counseil de Recherche en Sciences Humaines du Canada (410-91-1514) and from Loto-Quebec.     

Insurance problems and pathological gambling

A survey of 241 members of Gamblers Anonymous was conducted in order to find out the impact of pathological gambling on the insurance industry and whether Gamblers Anonymous reverses that impact. Fifty-two percent of the respondents cashed in, surrendered, lapsed or had policies revoked for non-payment. Forty-six percent borrowed on or used the cash value of their life insurance policies while gambling. Forty-seven percent admitted to some form of insurance related fraud, embezzlement or arson in connection with their gambling. The cost to the insurance industry was estimated at 66 billion dollars in surrendered policies and 33 billion dollars in fraud. Attendance at Gamblers Anonymous reversed much of this loss as members picked up new policies and engaged in programs of restitution after attendance. A discussion is made of the insurance related activities in terms of the usage of options up to and including suicide. Possible insurance industry responses are presented.     

The prevalence of problem and pathological gambling: A critical analysis

Prevalence of pathological gambling refers to the percentage of cases of pathological gambling occurring in the community at a given time. Prevalence studies conducted in different principalities throughout the world are reviewed, and it is found that none of them conforms to this definition of prevalence. The major error in all but the most recent surveys conducted is identified as the use of questions which ask whether gambling-related problems have ever occurred rather than whether they are currently occurring. This error will lead to an over-estimation of the prevalence of pathological gambling in society. The second major error identified in nearly all studies involves the accuracy of the screens being used to assess whether or not an individual is a pathological gambler. Concerns about the efficiency of the South Oaks Gambling Screen have not yet been satisfactorily resolved. None-the-less, the widespread use of the South Oaks Gambling Screen has made a valuable contribution to international comparisons of prevalence studies. Future work that explores the emerging relationship between levels of personal expenditure on gambling, types of gambling product and gambling-related problems are recommended.     

Impulsivity,compulsivity and pathological gambling: an exploratory study of pathological gambling as an impulsivity-compulsivity spectrum disorder

The current study was conducted to examine pathological gambling as an impulsivity-compulsivity spectrum disorder. University students (N=162) who gambled a minimum of twice monthly completed measures of impulsivity, compulsivity and pathological gambling. Instruments completed included: measures of problem gambling severity (South Oaks Gambling Screen, NORC DSM-IV Screen for Gambling Problems, Canadian Problem Gambling Index, Victorian Gambling Screen), the Padua Inventory, the Barratt Impulsivity Scale and the Tridimensional Personality Questionnaire. Results supported previous research indicating that pathological gamblers had elevated scores on measures of impulsivity and compulsivity, as well as personality factors correlated with these two constructs. Moreover, impulsivity and compulsivity were found to be interrelated as proposed by the impulsivity-compulsivity spectrum model.     

The prevalence of excessive and pathological gambling in Australia

Prevalence rate estimates were made for four levels of excessive gambling in Australia. Poker machine players (N=398) and off-course bettors (N=172) in the Australian Capital Territory were surveyed on their gambling. Four increasingly strict levels of excessive gambling were defined. Prevalence rates for each level were estimated for the general population using results of two commercial surveys run concurrently with this research. Estimates ranged from 1.73% of the population for the most liberal level to 0.25% of the population for the most strict. The fourth level is the most psychologically adequate and so 0.25% is the most appropriate estimate. While no direct correspondence to the current DSM-III could be found, an estimate in terms of the revised DSM-III for pathological gambling was at most 0.25% of the population. This estimate may further fall in those places where gambling facilities are less available.     

Pharmacological treatments of pathological gambling

Medication treatment studies have demonstrated short-term efficacy of various SRIs, opioid antagonists, and mood stabilizers in sub-samples of adult treatment seeking pathological gamblers. Pathological gambling is frequently comorbid with bipolar spectrum disorders, substance abuse/dependence, and attention-deficit/hyperactivity disorder (ADHD), and comorbidity may influence treatment response in pathological gambling. This review focuses on recent research examining the treatment of pathological gambling and highlights methodological challenges for future studies.     

Conflicts between activist research and academic success: Participatory research and alternative strategies

The article compares participatory research and alternative activist approaches, based on the literature on participatory research and interviews with nine successful sociologists who use alternative approaches. Participatory research, distinguished by high control over research by community members, equalizes power within the research process, but often retards academic publication and career advancement. The interviews show that successful academics retain control over their research, experience mild to severe conflicts with departments, and develop various strategies for combining activism and career success. All types of activist research are more effective in challenging inequality if they involve activist community organizations. Her research has focused on family, gender, and feminist and participatory methods. Recent publications includeLove in America, “Feminist Science,” and “Participatory Research” with Cathleen Armstead. Her current participatory research project explores “Family and Community Caring” in a Mexican-American community. Address for correspondence: Francesca M. Cancian, University of CA, Dept. of Sociology, Irvine, CA 92717.     

The prevalence rates of pathological gambling: A look at methods

Planning the gambling environment requires protection of the public's health, safety and welfare. Whereas most public gaming provisions and statutes address the public's fears of organized crime as well as some welfare needs, rarely do they safeguard the public's health regarding the spread of the mental disease known as pathological gambling. Measurement of the prevalence and incidence of this disease would enable policy planners to evaluate both the state's responsibility for an epidemic and the adequacy of publicly funded treatment programs. The purpose of this paper is to examine the methods which underlie three different estimates of the prevalence rate of pathological gambling and to critique them in the light of sound epidemiological procedure. In 1975, the Institute for Social Research (ISR) of the University of Michigan conducted a national survey and a survey of the state of Nevada on behalf of the U.S. Commission on a National Policy Toward Gambling. Using discriminant function analysis coupled with subjective inspection of cases in the at-risk pool, the researchers estimated rates of probable and potential pathological gamblers. In 1984 and 1985, this author surveyed residents in the Delaware Valley and the state of Ohio using the cumulative clinical signs method which also posited rates of probable and potential pathological gamblers. In 1986, researchers at the Office of Mental Health for the State of New York employed a formal screening device to survey residents and proposed a rate of probable pathological gamblers and a rate of problem — although not pathological — gamblers. All three approaches produced different estimates. The utility of prevalence and incidence rate research in this field is threatened by a lack of consensus about the proper epidemiological procedure to be employed in arriving at these estimates. There is also confusion about the distinction between a probable and a potential pathological gambler. The planning purpose, method, validity and reliability of prevalence rate research about pathological gambling are addressed in this paper.     

Antisocial personality disorder and pathological gambling

The prevalence of antisocial personality disorder and its relationship to criminal offenses in pathological gamblers was investigated. A semi-structured interview schedule containing DSM-III criteria for antisocial personality and the California Psychological Inventory Socialisation subscale was administered to a sample of 306 pathological gamblers. Of the total sample, 35% reported no offense. Forty eight percent admitted to the commission of a gambling related offense, 6% to a non-gambling related offense, and 11% to both types of offense. Fifteen percent of subjects met DSM-III diagnostic criteria for antisocial personality disorder. Though these subjects were at greatest risk for committing criminal offenses, offenses were committed independently of DSM-III antisocial personality disorder in the majority of gamblers. It was concluded that features of antisocial personality emerged in response to repeated attempts to conceal excessive gambling and gambling induced financial difficulties.This study was supported by a grant from the Criminology Research Council. The views expressed are the responsibility of the authors and are not necessarily those of the Council. The contribution of Anna Frankova, Research Assistant, is gratefully acknowledged.     

Gambling and pathological gambling in adolescents

A survey of U.K. secondary school children (aged 11–16 years) was undertaken to enquire into the prevalence of adolescent gambling and pathological gambling on fruit machines, and related behaviours. Sixty-two percent of the children gambled on fruit machines, 17.3% at least weekly and 5.7% pathologically. Pathological fruit machine gambling was correlated with gambling for money on other games, cigarette and alcohol use, video playing, parental gambling, playing alone and an early start (8 years or younger). It was not correlated with age, gender or religion, and only weakly with parental occupation. The implications of the findings for future research and social policy are discussed.The author would like to thank the Economic and Social Research Council for funding this work through a Research Studentship Grant. The author would also like to thank Henry Lesieur, Ph.D. and reviewers of the Journal of Gambling Studies for their helpful comments on an earlier draft of this paper. Special thanks to Professor David Dunkerley for his invaluable support of this project.     

The role of natural recovery in alcoholism and pathological gambling

While most pathological gamblers, like most alcohol abusers, recover on their own, it seems likely that they are at greater risk for relapse than those who have been through successful treatment. Accordingly, a substantial increase in treatment resources for pathological gamblers, along with greater efforts to establish the effectiveness of these treatments, ought to receive national priority. If the data on alcohol-abusing self-changers are generalizable to self-changing pathological gamblers, the prognosis for gamblers who stop gambling all together is better than for those who aspire to controlled or nonproblem gambling. While pathological gamblers with comorbid substance abuse are more difficult to treat than those without it, the impact of comorbid substance abuse on the decision by pathological gamblers to change has not yet been explored, although it should be. Similarly, the impact of other Axis I pathology on pathological gambling self-change, especially depression and anxiety, should be thoroughly explored. The most pressing problem in this field appears to be definitional. As a consequence, until consensus is reached on a reliable, valid, and useful classification scheme for pathological gambling, both research and clinical efforts will continue to suffer.     

The New Zealand national survey of problem and pathological gambling

In New Zealand, awareness of gambling-related problems has increased in association with the legalization of new forms of gambling. This paper presents the methods and selected results from a national survey of gambling and problem gambling completed in New Zealand in 1991. While the primary aim of the study was to determine the extent of problem gambling in New Zealand, the study included a second phase intended to assess the validity and reliability of the widely-used South Oaks Gambling Screen as well as to examine other aspects of problematic involvement in gambling. The results of the two-phase study in New Zealand show that problem gamblers in different countries are remarkably similar in demographic terms as well as with regard to other risk factors associated with problematic gambling involvement. The New Zealand study of problem gambling points the way toward important research topics that will require further exploration in the future.This research was funded by the New Zealand Department of Internal Affairs and by the US National Institute of Mental Health (MH-44295).     

Individual outpatient treatment of pathological gambling

Recovery from pathological gambling is viewed as a process whereby the pathological gambler chooses to lose an addiction to gambling and maintains that choice while mourning the loss of the gambling. The self-induced and self-escalating addictive crisis leading up to that choice is explored, as is the crisis caused by the loss of the gambling itself. It is proposed that gambling provides the gambler with action, a method of dealing with stress aand avoiding unpleasant affect, and a variety of social, psychological, and existential benefits. The loss of gambling is seen as a complicated and significant one which elicits grief responses similar to those seen in response to other types of major loss. It is proposed that in the individual outpatient treatment of pathological gamblers, the therapist helps the recovering gambler to accept the loss of the gambling and learn to live a rewarding life without it. Four phases of treatment are suggested which correspond to stages of grieving and accepting the loss of the gambling.